News about organ transplantation swings from uplifting to disheartening. Newspapers carry frequent stories of acts of spontaneous solidarity by ordinary Indians donating organs of family members who have suddenly passed away due to catastrophic injuries, causing brain death. This donation is to complete strangers without any expectation in return. We have recently witnessed parents donating the organs of their babies who are brain-dead in what must be a state of unimaginable grief. There is also regular news of extraordinary scientific breakthroughs in transplantation. Transplantation is an example of solidarity, science and teamwork in healthcare.
Simultaneously there is news of scandals, often involving the buying of organs from the vulnerable. Last year, a Kolkata hospital was at the centre of a news investigation which described street children from Nepal being lured as kidney donors for wealthy Indian and foreign patients. More recently, newspapers reported what seems like an elaborate Myanmar-based ring which arranged paid kidney donors and got transplants performed in a prominent Delhi hospital by faking documents. The buying and selling of human organs is a very old and global phenomenon. It has been deemed illegal in most of the world including India. This is not just from a moral prism but also to protect the rights of the vulnerable. But organ commerce continues, given the acute demand and a world where the commodification of the body is normalised. However, selling organs still evokes revulsion. Also, unethical transplantation requires the collusion of expert doctors whose professional oaths condemn organ trading. Morality and ethics collide with market medicine.
There is something new, though, in the Myanmar news story. Transplantation has grown exponentially in India, largely in the private sector. Whilst public medicine focussed on primary care, the private sector seized the gap in tertiary care. Transplants need well-trained personnel, technology, advanced intensive care and an institutional drive for good outcomes. These conditions were met in an expanding private sector, especially corporate hospitals. We must acknowledge that this has made transplantation, especially of organs beyond the kidney, available to a section of Indians who previously couldn’t access it. But something else is also happening. The corporate health sector realised that there is a lot of revenue in medical tourism and transplantation. Many countries in South Asia, Central Asia and Africa have not been able to develop transplant facilities. It was a matter of time before patients travelled from these countries to India. Transplantation in India is relatively cheap for foreigners in comparison to the rest of the world though it continues to be costly for ordinary Indians — a strange dichotomy.
Medical tourism seems like a perfect industry that should be a win-win. What’s wrong if, in a globalised world, patients from other countries utilise India’s healthcare expertise and the country earns revenue? The logic of revenue assumes that profits made by the private sector are somehow ploughed back to Indians. But medical tourism for transplantation is somewhat different. For one, these are very sick patients who travel to a foreign country with an alien language and culture. Care of transplant patients doesn’t end with the operation. Both donor and recipient need close follow-up. It’s debatable how well this is achieved when they return. But the biggest challenge when a donor-recipient pair travels across borders is to establish a relationship and distinguish paid and voluntary donations. Embassies are supposed to issue certificates ruling out coercion or payment but experience suggests that they don’t follow due diligence. The next gatekeeper in India is Authorisation Committees who have the mandate to rule out trade. But conflicts of interest abound. Hospitals are interested in numbers and revenue. Transplant is a gravy train which many can board.
Hospitals now have marketing teams who fan out in India and neighbouring countries. In the absence of an organised mechanism informal referrals based on monetary commissions are the norm. Most foreigners are recruited through agents who organise travel and paperwork. It’s a moot question whether transplant doctors are aware or hoodwinked by forged paperwork. Doctors claim that it’s not their job to detect subterfuge. But their professional oaths put the onus on them also. It’s not difficult to detect paid donations if there is a will and interest in doing so.
In a country where trust in healthcare is rapidly under threat, news of a large number of foreigners getting transplants is double-edged. The project of deceased donation after death is dependent on high levels of trust in the transplant system. A few years ago, news of foreigners receiving heart transplants from deceased donors in Chennai hospitals under the laughable pretext that there were not enough Indian patients resulted in a significant drop in donations.
We are thus faced with another classic conundrum of scientific progress. Those dying of organ failure will desperately try to procure an organ and a transplant. If that’s the only way, they will travel across borders. And if there is an option they will pay. Given its current political chaos, there is hardly any kidney transplantation in Myanmar. What else will a patient who needs it do when they know it’s available in neighbouring India? And what will a private hospital with the capacity to perform the procedure do but deliver it quickly and earn revenue? A monetised health system will seize any opportunity by legitimate — but if needed even illegitimate — means.
As the world has shown, donation after death is the future of organ transplantation. In India, we continuously appeal to ordinary Indians to donate organs after death. The campaign has also been led by the PM. But will citizens be altruistic if they sense scandal? Also, is it fair that we exhort them to donate but if they need a transplant most can’t afford one? Every news on organ transplantation poses difficult questions and tests us collectively.
The writer is a Mumbai-based surgeon
login
who are we?
contact us
qosheapp
Toi Staff
Gideon Levy
Belen Fernandez
Andrew Mitrovica
Mort Laitner
Rami G Khouri
Ali Fathollah-Nejad
Nikkei Editorial
visit website
